Project design
This project developed from a needs assessment completed in June 2017 (Appendix A).
The needs assessment consisted of a survey with questions concerning the use of mirror box therapy, why therapists were using or not using, and if they were using a protocol. From the needs assessment, it was determined that some occupational therapists were not using mirror box therapy due to not knowing about the intervention or not having access to a mirror box. If therapists were using, they were not using for the stroke population and instead using for pain management in patients with complex regional pain syndrome.
This study utilized a mixed methods sequential transformative design to determine the impact of education on mirror box therapy on occupational therapists’ attitudes and behaviors towards use and their clients’ occupational performance outcomes following use. Hospital and university Institutional Review Board (IRB) approval from obtained (See Appendix B). The study was divided into two parts. Part A of this study was to determine if education on mirror box therapy could change the attitudes towards the use of the intervention and evidence-based practice amongst occupational therapists. Part B of this study was to determine if the use of mirror box therapy could impact occupational performance outcomes of patients with CVA and the attitudes toward use of mirror box therapy of the therapists implementing the intervention.
Figure 6 demonstrates organization of Parts A and B of this study.
Figure 6. Organization of Capstone Project
Setting
The study was completed at two suburban southeast facilities. These hospitals provided the opportunity to work in the acute care, inpatient rehabilitation, and skilled nursing settings.
Having a variety of practice settings available allowed for a diverse collection of therapists and clients to partake in the study. Seventeen occupational therapists with varying levels of practice experience, averaging over fourteen years, were recruited to participate in the educational series.
This included eight acute care therapists, four inpatient rehabilitation therapists, and five skilled nursing therapists. The acute care setting offered two hundred and forty beds, inpatient
rehabilitation offered fourteen beds, and skilled care offered twenty-four short term beds.
Inclusion/exclusion criteria
The occupational therapists in the study were selected from a convenience sample of those working in the hospital systems. Therapist choice was based on those that would have
Part A: Education on Mirror Box Therapy
• Component 1
• 2 part Educational Series
• Session A
• Session B
• Component 2
• Focus Group A
Part B: Implementation of Mirror Box Therapy
• Component 1
• Use of mirror box therapy with patients with CVA
• Component 2
• Focus Group B
access to treating patients with CVA in their assigned setting. From the twenty-six therapists working for the corporation, ten therapists were excluded from this study. Of those ten occupational therapists, eight therapists specialized in hand therapy and did not work directly with patients with CVA. One therapist worked only in the pediatric setting and therefore did not have access to adult patients with CVA. One therapist worked exclusively with the neurological population and had used mirror box therapy in treatment, possibly presenting a biased attitude towards the intervention, therefore that therapist was excluded from the study.
Recruitment of patients with CVA was also based off a convenience sample. Adult patients that were currently admitted onto the acute care, skilled care, or inpatient rehabilitation units of the two hospitals were available for inclusion in this study. Inclusion criteria for these patients included: diagnosis of CVA with current evidence of hemiparesis or hemiplegia and/or evidence of sensory deficits. Exclusion criteria included clients with CVA but not medically stable, no motor or sensory deficits, and those with impaired cognition resulting in being unable to follow directions to participate in the intervention as determined upon the occupational therapist’s evaluation.
Project Methods
Part A. Part A: Component 1 of this study began with a two-part educational series for seventeen occupational therapists in the acute care, inpatient rehabilitation, and skilled care settings (See Appendix C). Each session lasted approximately seventy-five minutes each. The first session began with gaining consent from the occupational therapists followed by a quantitative pretest to determine their knowledge of mirror box therapy (See Appendix D).
Questions reviewed what deficits and diagnoses could be treated with mirror box therapy as well
as benefits of use to the occupational therapist and the patient with CVA. Their first session included education on what mirror box therapy is, what diagnoses could be treated with this intervention, the deficits that can be addressed by this intervention, the difference between simple and task-oriented mirror box therapy, and the importance of this intervention’s use with the stroke population. The session ended with a discussion of how to build a mirror box,
materials that could be used, and the importance of teaching our patients how to build and use for follow through upon discharge to home. The second session began with a brief review of the first session followed by each department using the mirror box to complete both simple and task-oriented activities amongst therapists to gain an understanding of what their patients may
experience. This session also included a review of the current evidence supporting the use of mirror box therapy with patients with stroke broken down by acute, subacute, and chronic stages of recovery. The discussion was followed by a brief overview of the Part B: Component 1 of the study involving data collection on the use of mirror box therapy with patients with CVA. A quantitative post-test was given, and all questions and answers were reviewed in group discussion following completion of post-test. Part A: Component 2 involved completion of a qualitative survey and 25-minute focus groups to discuss expectations of the learning, intentions of future use of mirror box therapy, and intentions of future use of evidence-based practice (See Appendix E). Peer debriefing was completed at the end of all focus groups.
Part B. Part B: Component 1 of this study included having one occupational therapist from acute, inpatient rehabilitation, and skilled care, three occupational therapists total, incorporating mirror box therapy into practice for a period of four weeks. Patients with CVA were included in the study at any time during the four-week period. Patients were recruited by the therapists after occupational therapy orders had been received and it was determined the
individual had motor or sensory deficits of the affected upper extremity. Participant consent was obtained for participation in the study by the assigned occupational therapist. Duration of mirror box therapy use was dependent upon the patient’s length of stay, with treatment being no longer than the four-week period. Mirror box therapy treatment was provided three to five times per week for ten to fifteen-minute sessions. Therapists were required to complete simple mirror box therapy for the allotted time period and may transition to task-oriented if the patient would benefit at that time. Simple mirror box therapy consisted of the unaffected limb completing supination, pronation, wrist flexion, wrist extension, ulnar deviation, radial deviation, digit flexion, digit extension, and digit opposition. Traditional occupational therapy was also
provided, and length was dependent upon practice setting and admission stay. See Appendix F for data collection sheet. At the end of data collection, Part B: Component 2 involved the three therapists that implemented the intervention in their practice setting participating in a 30 minute focus group to answer qualitative questions based on how using the mirror box has changed their confidence, their plans for use in the future, how their opinion on evidence-based practice has changed from educational series, and how they felt this experience of learning and using has impacted and will continue to impact their respective departments (See Appendix G). Peer debriefing was completed through the process of implementation and the focus groups.
Part A Data Collection
Part A: Component 1 data collection began with collection of the number of correct answers from the pre-test that occurred during educational session 1. These results were entered into a table in Microsoft Excel (2013). A post-test was provided at the end of educational session 2. These results were also entered into a table in Microsoft Excel to compare to pre-test number of correct answers.
Part A: Component 2 data collection occurred through four informal focus group at the end of the second educational session. Seventeen total occupational therapists participated.
Seven structured questions were presented with probing questions throughout. Seven open-ended questions were provided to identify optimal learning techniques for therapists, their impression of evidence-based practice, their impression of mirror box therapy, how they plan to use in the future, and how their confidence to use the intervention has been impacted. Each focus group was transcribed, but not audio recorded due to technical difficulties. Participant
pseudonyms were implemented to separate therapists from their responses. See table 2 below.
Table 2. Pseudonyms for Therapists Participating in Part A and Part B
Pseudonyms for Occupational Therapists Participating in Study
Therapist Setting Years Experience Gender
A1 Acute Care 12 F
* signified therapist also participated in Part B
Part B Data Collection
Part 2: Component 1 involved the three investigating therapists gathering information on time since onset of CVA, length of stay, and number of mirror box therapy sessions. These therapists also collected data in a pre-test, post-test manner for changes in range of motion (ROM), muscle strength, sensation, and Functional Independence Measure (FIM) score (See Appendix F). FIM scores on ADL levels were based on initial assessment of the patient and post use of the intervention for level of independence using a one to seven scale with one being dependent level of assistance and seven being complete level of independence (Keith, Granger, Hamilton, & Sherwin, 1987).
These areas were assessed as part of each patient’s evaluation upon receiving
occupational therapy orders increasing the reliability and validity of the assessment. Therapists were trained to utilize these assessments following standardization of procedures to ensure replication abilities in range or motion and manual muscle testing as well as the FIM. All three therapists that completed implementation of mirror box therapy were FIM certified.
Patients’ expectations of treatment and their opinion of the treatment after completion was also collected at the end of each session. All areas of data were collected after each session.
All data was entered into table in Microsoft Excel for comparison. Specifics of assessment for each area listed in Table 3 below.
Table 3. Outcome Measures for Patients with CVA Data Collection
Outcome Measures Part B Component 1
Range of motion Shoulder flexion, shoulder extension, elbow flexion, elbow extension, supination,
pronation, wrist flexion, wrist extension
Muscle Strength Shoulder flexion, shoulder extension, elbow flexion, elbow extension, supination,
pronation, wrist flexion, wrist extension
Sensation Intact, hypersensitive, diminished, absent
FIM Eating, grooming, bathing, upper extremity
dressing, lower extremity dressing
Part B: Component 2 utilized a focus group with the three investigating therapists at the end of the four-week data collection period. Seven open-ended questions were posed including how using mirror box therapy has changed their confidence levels for future use, how their impression of evidence-based practice has changed, how their impression of mirror box therapy has changed, how they felt this study has changed attitudes towards the intervention in their departments, and how they intend to use evidence-based practice and the intervention in the future. Two therapists, the acute care and inpatient rehabilitation therapist, attended the focus group which was recorded using Samsung voice. The skilled care therapist was unable to attend, and a phone interview was conducted. This interview was not recorded, but comprehensive notes were taken throughout. Both the focus group and phone interview were transcribed by hand.
Data Analysis
Quantitative Data. Part A: Component 1 was assessed by collecting data on the percentage of correct answers at the pre-test versus the number correct at post-test and what questions had the greatest amount of change. Sample t tests were used to compare pre and posttest correct scores (Taylor, 2017). This determined the impact of the educational series in changing knowledge through incorporating all forms of learning: auditory, visual, and
kinesthetic learning.
Part B: Component 1 implemented use of mirror box therapy to collect data on changes in range of motion, muscle strength, pain, and FIM levels. Range of motion measures were compared through the degrees of change. Manual muscle strength was recorded in fractions.
Due to incorporation of positive and minuses in documentation of these levels, the fractions were converted to a nominal scale to compare data (Table 4). Sensation was assessed using a verbal feedback scale. These responses were also converted to a nominal rating scale for analysis (Table 5). FIM levels were also based on nominal scale with word association for levels of assistance (Table 6). Data for each patient and each area of assessment was compared. Paired t-tests were run to determine if changes were significant.
Table 4. Nominal Scale for Manual Muscle Strength
Manual Muscle Strength Scoring
Rating Nominal Scale
Association
5/5 10
4/5 9
4-/5 8
3+/5 7
3/5 6
3-/5 5
2+/5 4
2+/5 4
2/5 3
2-/5 2
1/5 1
0/5 0
Table 5. Nominal Scale for Sensation (Wordpress, n.d.)
Sensation Scoring
Sensation Nominal Scale Association
Absent 0
Hypersensitive or Diminished 1
Intact 2
Table 6. Nominal Scale for FIM Changes (Keith et al., 1987)
Functional Independence Measure (FIM) Scoring FIM Word Association FIM Nominal Scale
Association
Independent 7
Modified Independent 6
Supervision 5
Min A 4
Mod A 3
Max A 2
Dep A 1
Qualitative data. Focus groups were completed post educational series in Part A:
Component 2 and post use of mirror box therapy with patients with CVA in Part B: Component 2. This data was combined for analysis to determine the full extent of the experience of learning about mirror box therapy and utilizing in practice while developing a deeper understanding of why and how a change in attitude toward use occurred. Following transcription of all sessions, Braun and Clarke (2006)’s six phase process of thematic analysis was used. After transcription and familiarization with the information, data was initially coded. All data was reviewed, and initial codes were generated. From this, identification of broader themes were found to organize information. Upon review of themes, information was reorganized or discarded to be checked in
relation to initial codes and overall data. The next step was refinement of emerging themes, labeling of these themes, and development of discussion of the therapists’ experiences.
To strengthen the validity of the Part A of the study triangulation was used through the combination of a quantitative pre-test/post-test and qualitative focus group. This allowed for two strategies to interpret information on learning (Lysack, Luborsky, & Dillaway, 2017). The
changes demonstrated from the quantitative pre-test post-test questionnaire would be further expanded upon in the qualitative focus group to develop a better understanding of the learning experience in this sequential transformative design
Ethical considerations
One of the ethical considerations was that participation by occupational therapists and patients with CVA was voluntary. Occupational therapists and patients signed consents prior to participation in Part A and Part B of the study. Therapists implementing mirror box therapy in practice settings were trained and approved to gather consents from patients with focus on educating the patient on the purpose of the study, expectations, and risks involved.
Creswell (2014) discussed an important ethical consideration of not disrupting the site.
This held true in all settings as there needed to be little to no interference with other staff or patients so the focus would be on the use of mirror box therapy. The hospital setting has its own dynamic with multiple disciplines requiring time and space to interact with patients. For Part B:
Component 1, the setting was a hospital room or therapy gym. This was not the natural home setting for the patient but was considered their temporary normal. If the participants in this study altered the environment that the intervention took place in through changing the setup of the treatment room, providing distractions from other disciplines, or completing the intervention
outside of scheduled treatment time, they would be disrupting the temporary setting for the intervention to take place in which may have negative implications for the ability to use mirror box therapy. Distractions could be present taking away from the impact of the intervention.
The intervention of mirror box therapy may or may not be successful in changing patient outcomes in each setting, but the intent of the project was to determine if results of this study could be supported with current evidence. Creswell (2014) stressed the importance of not only providing positive results but providing negative responses as well to define the experience. For reporting results of perception of therapists towards learning, therapists needed to be prompted to be honest and forthright with their opinions (Taylor, 2017).
The final ethical consideration was concept of nonmalificence. AOTA (2015) defined this as “personnel shall refrain from actions that cause harm” (p. 3). Through the educational series, therapists learned what criteria patients needed to meet to benefit from mirror box therapy. When implemented, it was assumed that therapists would follow these guidelines and not place patients at undue risk for harm. This was reinforced through signing of consents for the therapists participating in part one of the study and the patients participating in part two of the study. The Institutional Review Board Approval was received from the healthcare facilities and also Eastern Kentucky University.
Timeline of project procedures
After IRB approval, the Part A educational series began on January 14th, 2019 and ran for two weeks between both Wheeling Hospital and Belmont Community Hospital. Part B, implementation of mirror box therapy, ran for four weeks from January 28th, 2019 through February 22nd, 2019 in the acute care, inpatient rehabilitation, and skilled nursing settings.
Treatment was provided three to five times per week for ten to fifteen minutes per session. Data was analyzed for both Parts A and B of the study and results were shared with occupational therapists that participated in all parts of the project. Total time for this study was seven weeks.
Timeline for entire project in Figure 7.
Figure 7. Timeline of implementation
3/4/19-3/8/19: Wrap up
Quantitative Data Analysis Qualitative Data Analysis
1/28/19-3/1/19 Part B: Implementation of Mirror Box Therapy
Component 1: 4 week use of intervention Component 2: Focus Group B
1/14/19-1/25/19 Part A: Education on Mirror Box Therapy
Component 1: Quantitative
Pre-test/Post-test Component 2: Focus Group A